Accounting for health: Calculation, paperwork, and medicine, 1500–2000

By Manchester University Press

Whether in the Swiss countryside or in a doctor's office in Boston, in German, English or French hospitals or within multinational organizations, with early vaccinations or with new pharmaceuticals from Big Pharma today, or in early modern Saxon mining towns or in Prussian military healthcare – for at least 500 years, accounting has been an essential part of medical practice with significant moral, social and epistemological implications. Covering the period between 1500–2000, the book examines in short case studies the importance of calculative practices for medicine in very different contexts. Thus, Accounting for Health offers a synopsis of the extent to which accounting not only influenced medical practices over centuries, but shaped modern medicine as a whole.

• Language: English
• Publisher: Manchester University Press
• Release date: Jan 12, 2021
• ISBN: 9781526135186

Book preview

List of figures

0.1 Poor Box at St. Bartholomew Hospital, London (photograph by Axel C. Hüntelmann)

1.1 Double page from Hiob Finzel's Rationarium (RSBZ QQQQ1a, 128–9)

1.2 Finzel's annual income 1573–88 in gulden

1.3 Double page from Hiob Finzel's Rationarium (RSBZ QQQQ1, 158–9)

2.1 Three practitioners in and around Geneva

2.2 Page of Joseph Despine's ledger (Archives départementales de Savoie, Fonds Despine, 11 J 106)

2.3 First page of Catherin Pichollet's ledger (Archives d’Etat de Genève, Manuscrit historique 201)

2.4 Page of Louis Odier's ledger/Livre de comptes de Louis Odier (Bibliothèque de Genève, Ms. Fr. 5647/9)

2.5 Page of Odier's clinical pocket books (Musée d’histoire des sciences, Z 92/2 Diarium clinicum)

3.1 Cases under observation 1 May 1914 to 1 May 1915 (Joslin, Present-day Treatment and Prognosis in Diabetes, p. 486)

3.2 Reporting scheme for results of urine sugar tests (Joslin, A Diabetic Manual for the Mutual Use of Doctor and Patient, 4th edn, p. 54)

3.3 Drawing by Mr Rainsford showing the colours of his urine sample in correlation with his daily diet (JDCHA, Box 20, Folder 6) Copyright © Joslin Diabetes Center. All rights reserved. Reprinted with permission.

3.4 Equivalency table for determining the quantities of carbohydrates, fats, and proteins and their caloric value in common foods. (Joslin, A Diabetic Manual for the Mutual Use of Doctor and Patient (6th edn), p. 51)

3.5 Post-treatment history of patient no. 16158 (front and back side). These file cards brought together registration categories, examination results, and the cause of death onto a single card (JDCHA, Box 5, Folder 2) Copyright © Joslin Diabetes Center. All rights reserved. Reprinted with permission.

4.1 Royal Charité Hospital in Berlin, hospital and Ökonomie buildings, surrounded by fields and garden, around 1730 (Eller, Nützliche und auserlesene medicinische und chirurgische Anmerckungen, Berlin 1730)

4.2 ‘Consumptions-Etat’ – Designation of meals for ‘Officianten’ and ‘Deputanten’, June 1800 (HUA CD Nr. 1357, fol. 121)

4.3 Normal diet schemes (Hauptdiätverordnung), compiled and accumulated for all patients (Esse, Krankenhäuser, Beilage II, p. 271)

4.4 Form III breaking down the quantities of single ingredients (here i.e. coffee, sugar […], herring, various baked fruits, cabbage) for the calculation of the daily diets (Esse, Krankenhäuser, Beilage III, pp. 278–9)

4.5 Calculation of catering days for 1902 (HUA CD No. 1200)

4.6 Recalculation of diet schemes (Speisezettel) 1st table, January 1897 (HUA CD No. 1259)

5.1 Expenditure, General Voluntary Hospitals Leeds and Sheffield, 1913–28

5.2 Expenditure, Lille Hospital Commission, 1910–28

6.1 Forms such as this ‘Subscription Ticket’ were used during the fundraising campaign for the Institute of Cancer in Leuven during the 1920s (UAL, ACA, 1046)

6.2 A standardised form, filled out for the service of Pediatrics, 1952 (UAL, AVDS, 272)

8.1 A Comparative View of the Natural Small-Pox, Inoculated Small-Pox, and Inoculated Cow-Pox, by John Addington, by Order of the Medical Council of the Royal Jennerian Society for the Extermination of the Small-Pox (London: Nichols and Son, [1803], Library of the Royal College of Surgeons)

8.2 Register of Inoculations, Address of the Royal Jennerian Society, for the Extermination of the Small-Pox. With the Plan, Regulations, and Instructions for Vaccine Inoculation. To Which is Added, a List of the Subscribers (London: W. Phillips, 1803, p. 52, Wellcome Library)

8.3 Excerpt from RJS vaccination register, September 1804 (Minutes of the Medical Committee of the RJS, Wellcome MS 4304, 6 September 1804)

9.1 The CRF of the Levoprotiline study: Depressive mood, anxiety, agitation, inhibition, apathy, insomnia, and physical complaints (Courtesy of IGM Berlin, Arzneimittelforschung)

9.2 Target symptoms shape the efficacy of the CG antidepressant Ludiomil® (Maprotiline). Five items on the Hamilton-Scale affected significantly by the three drugs in different ways (compare Kielholz, Depressive Zustände, p. 256)

10.1 Esther Smucker and Mary Warye were admitted to the NIH Clinical Center in September 1965. Delbert Nye was director of NIH's Normal Volunteer Patient Program, which Esther and Mary joined to serve as ‘normal control’ research subject for the Mennonite church. They agreed to be the unit leaders for the Mennonite Voluntary Service group placed at the Clinical Center, which involved serving as the church's local accountants. This staged arrival scene, dated nine months after their actual admission, was likely photographed for publicity, though it was never ultimately used in promotional materials. The original photo caption reads: ‘Esther Smucker shakes hands with Mr. Delbert Nye, director of the normal control patient program. Mary Warye watches in the background’ (MCC, National Institutes of Health, 1955–66, box 4, file 74, MCC Photos, Voluntary Service, Photograph, IX-13.25)

10.2 The NIH Clinical Center opened in 1953 on the agency's main campus in Bethesda, Maryland, and started a new programme, the Normal Volunteer Patient Program, to get essential research material for scientists: healthy human subjects for medical experiments. Esther and Mary, like other ‘Normals’, lived in hospital rooms for weeks, months, or years alongside sick patients (US NIH National Library of Medicine, IHM database, Image ID: A014533, Unique ID: 10144118)

10.3 To get healthy human subjects for scientists’ research in the Clinical Center, the NIH established a legal instrument for buying research supplies from vendors: the ‘procurement contract’. The second line item under ‘renewal contracts’ in the NIH's 1956 inventory of contracts is contract 103-55, ‘Volunteer Service’ from Mennonite Central Committee (National Archives and Research Administration, College Park, Maryland, Contracts continuing 1955 and 1956, box 15, record group 511)

10.4 The Mennonite church and the Church of the Brethren signed the first contracts with the NIH for healthy human subjects, which were recruited through the churches’ ‘voluntary service’ programs. The NIH paid the church organisations the cost of a stipend for voluntary service workers and a 10 per cent ‘processing fee’. The churches also reimbursed voluntary service workers at NIH for their additional expenses, such as ‘education and recreation’ activities, and ‘operation and administration’ costs including phone and postage for church business. From among the group of voluntary service workers living at the Clinical Center, the churches assigned a ‘unit leader’, who worked as a vernacular accountant for the church to manage its local finances (MCC, Folder NIH MSU, Series MCC IX-6–3, Mennonite ‘Report of unit income and expenses’, c. 1966)

11.1 Aggregate manpower tables of the Hanoverian regiments in the Netherlands from May 1745 to April 1746 (NLA Hann, Hann 41 III, Nr. 16, fol. 178–9)

11.2 Monthly return from the Prussian field hospitals in Saxony during the Seven Years’ War for the period from 6 November to 2 December 1760 (GStA PK, I HA Rep. 96, Nr. 85 U 2)

12.1 ‘Penny box’ of a smelters’ society (Hüttenknappschaft Freiberg) (Stadt- und Bergbaumuseum, Freiberg, Inv.-Nr. 51/92, photo by Wolfgang Thieme)

12.2 House of the Mining Brotherhood, Schwaz, Tyrol, showing hospital and sickbeds, c. 1510–50 (‘Schwazer Bergbuch’ [1556], illustrated in Bartels, Bingener, and Slotta [eds], Schwazer Bergbuch, Bochum 2006)

12.3 Quarterly invoice for medications given to miners, 1750 (Bergarchiv Freiberg, 40006, Bergamt Altenberg, No. 290)

12.4 Quarterly register of medications given to miners, with auditing annotation at bracket in the upper left margin, 1806–11 (Bergarchiv Freiberg, 40013 Bergamt Marienberg, No. 224)

13.1 Members and sickness funds in Gothenburg, 1901–40 (Kommerskollegium, Arbetsstatistik. B, Registrerade sjukkassors verksamhet [Stockholm: 1905–1912]; Socialstyrelsen, Registrerade sjukkassor [Stockholm: 1915–1936]. Pensionsstyrelsen, Erkända sjukkassor år 1940, Sveriges officiella statistik: Försäkringsväsen [Stockholm, 1943])

13.2 Income, expenditure, and financial assets in SSBK 1899–1930 (GLA, SSBK, vol. 42, annual statistic reports)

14.1 Health budgets in the International Health Yearbooks. Left: Germany, 1927 (extract); right: Italy, 1928

14.2 Comparative tables of health expenditure in The Cost of Medical Care, pp. 202–3 (International Labour Organization 1959)

14.3 Examples of comparative health expenditure data from the WHO Global Health Expenditure Database: Current health expenditure as a percentage of gross domestic product, selected OECD countries, 2000–15 (Source: http://apps.who.int/nha/database/ViewData/Indicators/en [accessed 21 May 2018]

List of contributors

Helene Castenbrandt is a researcher in the Department of Economic History at Lund University in Sweden where she is working on the history of long-term sickness absence. Castenbrandt's dissertation (2012) dealt with dysentery in Sweden between 1750 and 1900 as a demographic and medical history of a disease. Her main research interests involve medical history, demographic changes, and population history. Recently she published an article in Economic History Review (2018) on ‘Trends in morbidity: national statistics on sickness claims among the working population in Sweden, 1892–1954’.

Barry M. Doyle is Professor of Health History at the University of Huddersfield. His teaching and research interests cover the political, social, and economic history of urban Britain in the late nineteenth and twentieth centuries. He has a particular interest in the development of health care systems before welfare states and the history of hospitals in Britain and Europe; the history of first aid and voluntary health care; and the development of maternity services in a global context. In 2014 he published The Politics of Hospital Provision in Early Twentieth Century Britain (Routledge).

Oliver Falk is Research Associate at the Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich. His main research areas are the history of diabetes therapy, doctor–patient relationships throughout the twentieth century, the epistemology of therapeutic self-techniques and medical writing, as well as sociology of knowledge in medicine. He recently published an article on the patient as an epistemic factor: ‘Der Patient als epistemische Größe’, Medizinhistorisches Journal 53 (2018).

Jean-Paul Gaudilliere is Senior Researcher at the Center for Research in Medicine, Science, Mental Health, and Society (CERMES 3) of the French Institute of Health and Medical Research. In 2015, he received an Advanced Grant from the European Research Council on the historical transformation ‘From international public health to global heath: knowledge, diseases, and the government of health since 1945’. He has also worked and published on the relationships between science, medicine, and the pharmaceutical industry and the regulation of drugs in the twentieth century, as well as on medicine and risk management in cancer-related environmental health since the 1960s. He is involved in the volume Global Health and the New World Order that will be published in 2020 in the same book series as the current volume (Social Histories of Medicine).

Volker Hess is Chair of the Institute for the History of Medicine at the Charité Medical School in Berlin and Affiliated Professor in the History Department of the Humboldt University. In 2011, he received the Advanced Investigator Grant from the European Research Council for a collaborative project with J. Andrew Mendelsohn in reconstructing the ‘paper technologies’ of medical practices, based on their article in the journal History of Science (2010). In 2019, he was awarded an ERC Synergy Grant to study Europe's postwar history through the lens of medicine. With regard to the topic of the current volume, he edited with Alexa Geisthövel a volume on medical expertise (Medizinisches Gutachten. Geschichte einer neuzeitlichen Praxis, Göttingen 2017).

Axel C. Hüntelmann is Postdoctoral Research Fellow at the Institute for the History of Medicine at the Charité Medical School in Berlin. He has worked and published on the German Imperial Health Office (PhD 2007) and other European public health institutions between 1850 and 1950; scientific infrastructures; the history of laboratory animals; the production, marketing, and regulation of pharmaceuticals in Germany and France; and has written a biography on the immunologist Paul Ehrlich (2011). He trained in accounting as well as history and is currently finishing a book on accounting and bookkeeping in medicine (1730–1930).

J. Andrew Mendelsohn is Reader in History of Science and Medicine at Queen Mary University of London. He co-led with Volker Hess the ERC-funded research project ‘How physicians know, 1550–1950’. His research focuses on ways of writing and knowing and their effects in science and medicine; observation, experimenting, classifying, and predicting; and industrializing life and its sciences from the eighteenth to the twentieth century. Recent publications include the co-edited volume Civic Medicine: Physician, Polity and Pen in Early Modern Europe (2020).

Theodore M. Porter is Distinguished Professor of History at University of California, Los Angeles. His research integrates history of data, statistics, and quantification within the history of the human sciences. His most recent book is Genetics in the Madhouse: The Unknown History of Human Heredity (Princeton University Press, 2018).

Sebastian Pranghofer is Lecturer in Early Modern History at the Helmut-Schmidt-University in Hamburg. His main areas of research are early modern military administration and logistics; war, medicine, and disease; as well as the history of early modern anatomy. On military medicine, he recently published ‘Zur Anatomie beurlaubt. Qualifizierung und Karrieren von Feldscheren in Berlin und Hannover im 18. Jahrhundert’, in Johanna Bleker, Petra Lennig, and Thomas Schnalke (eds), Tiefe Einblicke: Das anatomische Theater im Zeitalter der Aufklärung (Berlin 2018).

Philip Rieder is Senior Lecturer (maître d’enseignement et de recherché) at the Institut Ethique Histoire Humanités (IEH2), University of Geneva. He has published widely on a variety of topics pertaining to the social and cultural history of medicine in the early modern period, namely the history of the patient, of medical practices, and of healers. Recently he edited with François Zanetti a volume on Materia Medica: savoirs et usages des médicaments aux époques médiévales et modernes (Geneva 2018), with his chapter on the history of the apothecary.

Andrea Rusnock is Professor in the Department of History at the University of Rhode Island and was the editor of Osiris between 2009 and 2017. She has worked and published widely on science and medicine in the Enlightenment; the history of quantification; public health and the environment; and on the history of vaccination. In 2002, she published Vital Accounts: Quantifying Health and Population in Eighteenth-Century England and France (Cambridge University Press).

Christopher Sirrs is Postdoctoral Fellow in the Department of History, University of Warwick. At the time of writing, he was a Research Fellow at the Centre for History in Public Health, London School of Hygiene and Tropical Medicine. An historian of medicine and public health, his research encompasses the history of global health, health systems, and occupational health and safety. In 2020, he started a research project funded by the Wellcome Trust, exploring the history of safety in the British National Health Service. His most recent publication is a journal article in the International History Review, exploring the International Labour Organization's approach towards health system financing in the second half of the twentieth century.

Laura J. M. Stark is Associate Professor at Vanderbilt University, Associate Editor of the journal History & Theory, and creator of the Vernacular Archive of Normal Volunteers housed at the Countway Center for the History of Medicine. Her research focuses on science and technology studies; social theory; and the history of science and medicine from feminist and postcolonial perspectives. In 2012, she published Behind Closed Doors: IRBs and the Making of Ethical Research with the University of Chicago Press and in 2019 she won the Freidson Prize from the American Sociological Association for her article in Social History of Medicine: ‘Contracting health: procurement contracts, total institutions, and the problem of virtuous suffering in post-war human experiment’.

Michael Stolberg is Chair of History of Medicine in Würzburg, Germany. He has published widely on the history of early modern medicine. His most recent book is Gelehrte Medizin und ärztlicher Alltag in der Renaissance (Berlin: DeGruyter Oldenburg, 2020) and will be published in English (2021) as: Learned Physicians and the World of Medical Practice in the Renaissance.

Joris Vandendriessche is Postdoctoral Fellow of the Flanders Research Foundation (FWO) in the Cultural History since 1750 Research Group of the University of Leuven (Belgium). His research focusses on the history of scientific knowledge, medicine, and universities in the nineteenth and twentieth centuries. He is the author of Medical Societies and Scientific Culture in Nineteenth-Century Belgium (Manchester University Press, 2018) and Zorg en wetenschap. Een geschiedenis van de Leuvense academische ziekenhuizen in de twintigste eeuw (Leuven University Press, 2019). His current project engages with publishing practices and piracy in nineteenth-century science.

Introduction

Axel C. Hüntelmann and Oliver Falk

On 30 May 1751, after seven more people were admitted to a newly founded infirmary in Newcastle, the hospital's so-called poor boxes were opened, and ‘£9 18s. 10d. found therein’. In one of the boxes, there was a shilling, enclosed in a piece of paper with a short poem on it:

To serve the needy, sick and lame,

This splendid shilling freely came,

From one who knows the want of wealth,

And what is more – the want of health.

Beneath this roof may thousands find,

The greatest blessing of mankind;

And hence may millions learn to know,

That to do good's our end below;

That Vice and Folly must decay

Ere we can reach eternal day!¹

Poor boxes were common in many parts of Europe. They were located in front of hospitals, churches, and other places, notably as a part of poor relief systems. For instance, a similar box was located at the entrance of the Charité Hospital in Berlin in the eighteenth and nineteenth century. And as a relic of the past, even today a hospital visitor or patient who is entering or leaving St. Bartholomew Hospital in London from West Smithfield through the King Henry VIII gate can find a poor box opposite the former ‘Counting House’. On the surface of the heavy box is a slot to insert a donation to the hospital and those who cannot afford proper treatment (Figure 0.1).

cintro-fig-0001.jpg

0.1 Poor Box at St. Bartholomew Hospital, London.

In the past, the sealed poor box was opened at regular intervals by the key holders and in the presence of several witnesses. The box was emptied, the money counted, the amount registered, and the donation then put to use. Detailed and itemised information about how the money was spent was kept in account books and each year the hospital's treasurer reported all income and expenditures in a published ‘Annual Account’.

Although the revenue generated by poor boxes constituted only a small fraction of overall hospital income, these boxes illustrate the essence of accounting or, more specifically, accounting for health. Fundamentally, poor boxes represent accounting as a process of (countable) things going in and out, linking social and cultural preconditions and intentions (e.g. a system of poor relief), people (donors, processors, receivers), and the objects and materials involved. In this sense, poor boxes drew things together that, in their aggregate, reflect our understanding of accounting for health.

In this introduction, we will first frame what we mean by accounting for health by returning to the example of the poor box (1) and then summarise the current state of historical research (2). Then, after we have elaborated the volume's methodological approach (3), we will outline the book's structure (4) and sketch the different, deeply entwined dimensions of accounting for health (5).

Framing accounting for health

How does our understanding of accounting for health differ from other fields of accounting? What is so specific about accounting for health?

Accounting is about ‘how much’ and is usually assumed to be about money. It is viewed as a financial technology related to the administration of money, cost and costing, and the calculation of efficiency.² But the term ‘accounting for health’ involves both money and medicine and raises moral issues, given that making a living from medical treatment has ethical ramifications. Profiting from the ‘pain and suffering of other people’ (Chapter 1) was as problematic in 1500 as it is in today's debates about the economisation of medicine and the admissibility of for-profit hospitals.

The poor box illustrates that inserting a shilling into a slot is not just about money. Donations were made for a certain purpose and were laden with moral or social intentions. Because donors expected their money to be used for a specific purpose, treasurers had to provide information about the donor's gift – for instance, in published ‘Annual Accounts’ – and to account for its efficient and legitimate use. This accounting for health was not merely a matter of financial probity, but also about best medical practice, not least because it helped elicit further donations and encourage other prospective donors. For this reason, monetary income and medical outcome were correlated. Accounting for health involved information being collected, listed, and compiled in tables (for instance, about the number of patients treated and cured, about cure rates, and about changes in revenue sources or health outcomes over time) in order to demonstrate good medical practice.³

But what did good medical practice mean and who defined it? What was health and what was disease, and at what point did ‘not so healthy’ turn into ‘sick’? What criteria determined healthiness, and how and by whom were those criteria developed? In society as well as interpersonal communication, such criteria have regulatory functions that enable (or necessitate) action and that therefore have to be plausible and comprehensible. Inasmuch as health, disease, and medicine have a socio-political and moral dimension, disease and illness couldn't simply be described in vague and subjective terms – such as an absence of disease or a comprehensive physical, mental, and social well-being – but instead had to be objectified and legitimised according to general, enumerable criteria. In this transformation process, calculative practices like reckoning, counting, computing, or evaluating played an important role.

For centuries, accounting and calculative practices have comprised an essential part of medicine. As early as the sixteenth century, health and disease had been described in terms of a balance or imbalance of bodily fluids. In the eighteenth century, patients’ diets were calculated in grams, grains, or ounces of bread, meat, or fat, and pints of milk. Descriptions of human metabolism and internal secretions in the mid-nineteenth century likewise underscored the importance of calculative practices in medicine. And ever since, the once fluid transitions between ‘still healthy’ and ‘already ill’ have been clearly demarcated using threshold values. The normal and the pathological, and therefore the state of health and of medicine in general, have come to be determined by numbers. For instance, the number of blood cells or the proportion of blood sugar or uric acid in the blood has come to determine the state of health and disease in cases of anaemia, gout, or diabetes. At the end of the nineteenth century, new disciplines like nutritional science and calorimetry helped to establish methods for computing balanced diets as part of therapeutic approaches to stabilise and improve a person's health using precisely defined daily quantities of fats, proteins, and carbohydrates. Whether in research, therapy, or prevention, it became crucial to measure, count, or correlate everything that enters or exits the body.

Against this medical backdrop, accounting for health is a set of calculative practices and administrative techniques in which not only money but also goods and other countable objects are transformed into specific codes and formats that appear in (account- or case-) books, (double-entry) ledgers, lists, and tables. In this transposition, the status of the objects recorded is changed insofar as their availability is now no longer bound to their physical materiality; the countable objects have turned into manageable units, figures, and numbers that enable subsequent practices of reckoning, calculating, valuing, controlling, justifying, communicating, or researching. In this sense, accounting can be considered an administrative, scientific, and social technique. But this transposition generates not only a variety of figures and numbers, but also paper tools like ledgers and account books – the production of numbers itself was closely linked to accounting techniques and depended on, and was influenced by, the chosen form of recordkeeping.

State of research

Accounting for health brings together related perspectives and lines of research that have so far remained surprisingly unconnected. There are reams of literature on knowledge production in medicine or the life sciences, like the countless studies on laboratory science and historical epistemology from the Max Planck Institute for the History of Science or the Pickstone series on Science, Technology, and Medicine in modern history. In addition, scholars working in the field of health economics and other related areas have written extensively on the economisation of health and medicine,⁴ on the commercialisation of medicine, on the commodification of the body and of health, as well as on the history of the drug and health markets.⁵

But we aim to describe a more detailed accounting for health that incorporates calculative practices, paper technologies, medicine, and medical knowledge. In the following summary of current research, we first review the literature on the sociology and history of calculative practices. We then outline several research perspectives within the history of accounting. And, finally, we turn specifically to the history of hospital accounting.

(1) Following in the footsteps of Werner Sombart's and Max Weber's classical work on organisations, sociologists have recently been eager to provide a better, broader, and more realistic understanding of the significance of numbers and figures. According to these approaches, the social character of figures needs to be explored in terms of the conditions, possibilities, boundaries, as well as the conflicts evoked within organisations and society. Moreover, their social context and the social integration and interlacing of their use – from measurement to management, from reckoning to governing, or from calculating to constructing – needs to be analysed.⁶ At the same time, this approach attempts to compensate for a long interruption in theoretical debates and for a lack of systematic interest in calculative practices, as well as to answer the questions of whether and to what extent the massive mobilisation of numbers, measurements, and calculations might impair, support, or undermine social order.⁷

In this respect, Uwe Vormbusch's study Die Herrschaft der Zahlen is especially revealing because it illustrates how the cultural legitimacy of calculative practices varied widely over the course of their historical development. Thus, in the eighteenth century there were bitter debates about whether statistics on births and deaths should be produced, just as today we face the question of whether knowledge of prenatal and genetic diagnostics should be used to make life and death decisions.⁸ This illustrates, for example, the extent to which calculative practices can be connected with genuinely medical–historical questions that inform studies about the rise of political arithmetic and vital statistics, about risk calculation, about medical quantification, about calculative practices in clinical medicine, and about public health and epidemiology.⁹ The expanding influence of statistics from the eighteenth century onwards thus undermined the notion of mortality as a universal constant or as divine predestination, to the point that life and death could be seen not only to vary across regions, but also to depend on someone's sex and behaviour. Statistics thus became part of everyday social awareness. Their narrative expression can be found in the innumerable eighteenth-century prints that conveyed the emerging bourgeoisie's understanding of the connection between one's own behaviour and prospects for a long and healthy life¹⁰ and that eventually influenced the construction of the modern body in nineteenth-century hygienic and physiological discourse.¹¹

The arrival of a Foucauldian ‘quantitative dispositive’ was accompanied by a shift in the meaning of numbers, from a rather symbolic, mystical designation of size to a tool of ‘world surveying’ by state authorities in the early modern era, with considerable effects on social, economic, and scientific practices. That numbers produced by statisticians and accountants came to be regarded as ‘objective’, trustworthy, and reliable enough to serve as a basis for decision-making, was a process that developed over centuries.¹² For a number of years, early modern studies focused on the importance of statistics for the evolving absolutist territorial state, in particular with an emphasis on the emergence of quantifying and calculative practices related to natural resource acquisition, spatial perceptions, population surveys, military preparedness, tax surveys, etc. However, Lars Behrisch has pointed out that early modern studies have used the concept of statistics rather uncritically by tending to classify any form of numerical administrative technique as statistics. As a consequence, the question of why and when numbers, tables, and calculations began to influence perceptual patterns, arguments, and actions remains partly obscured. During the course of this shift in the meaning of counting and arithmetic practices, various forms of administrative manipulation came to be used as information collection practices, creating new forms for the non-statistical representations of numbers, such as tax lists, military recruitment lists, community registers, or catalogue entries. ‘Statistics does not create more or better knowledge; it first and foremost creates an entirely new kind of knowledge.’¹³ But the question is, what does this new knowledge mean for an important part of a society like medicine?

(2) Aside from sociological work on calculative practices, there are also numerous studies on the history of accounting, most recently by cultural historians like Jacob Soll and Jane Gleeson-White.¹⁴ An overview of this research is provided by the compendium on the history of bookkeeping published by John R. Edwards and Stephen P. Walker.¹⁵ In addition to the development of accounting practices (in particular double-entry bookkeeping), the focus lies on the historical development of accounting systems and the professionalisation and institutionalisation of those systems in corporate organisations and academic institutions,¹⁶ as well as on the gender-specific aspects of accounting.¹⁷ Furthermore, several publications from the London School of Economics around the group of Anthony G. Hopwood, Peter Miller, and Michael Power have, partly from a Foucauldian perspective, examined discourses on accounting, auditing, and governmentality.¹⁸ However, the number of publications directly related to the subject of medicine and the generation of medical knowledge is far smaller. Alistair M. Preston's ‘The birth of clinical accounting’ is worthy of special mention. Preston examines the extent to which the history of bookkeeping should not be seen merely as a continuous ‘improvement’ and development of calculative techniques resulting from shifting socio-environmental conditions, but instead, conversely, as a governmental technique in itself by which certain social conditions are regulated and influenced.¹⁹ Preston examines accounting in US hospitals and highlights two particular transformation processes: at the beginning of the twentieth century, the primary concern was to manage and control hospital costs, whereas the 1960s and 1970s were characterised by attempts to increase revenues and implement cost–benefit analyses. Preston shows ‘how changes in accounting thought and practice over the past 100 years are intertwined with changes in medical knowledge and practice, the establishment of hospitals as the primary sites for medical treatment, the emergence of private insurance, changing forms of government regulation and shifting socio-political attitudes towards the cost and provision of health care’.²⁰ In this respect, Preston's investigation relies mainly on discourses in health policy and (hospital) bookkeeping and can be included among numerous other studies on governmentality. However, the mathematical practices themselves – counting, measuring, calculating, and tabulating – receive little notice. Nevertheless, Preston's study is an important landmark for this volume, but it is also a solitary one in the research landscape, since Foucauldian studies on the history of double-entry bookkeeping and auditing ended abruptly in the mid-1990s. In this context, Uwe Vormbusch has written of the long interruption ‘in the theoretical discussion of calculative practices in economy and society’.²¹ And ever since, according to Peter Miller, ‘no more than rudimentary approaches of a sociology of calculative practices’ can be identified.²²

(3) Over the last twenty years, rich and substantial studies on the history of accounting in hospitals have been published. Focusing mainly on the monetary aspects of hospital funding and hospital finance, these studies take a completely different perspective and have little in common with the aforementioned sociological works. A good overview of the existing literature has been written by Florian Gebreiter and William J. Jackson.²³ The range of hospital finance and accounting practices is explored in the edited volumes by Martin Gorsky and Sally Sheard (2006, for Great Britain) and Alfons Labisch and Reinhard Spree (2001, for Germany).²⁴ These studies analyse the sources of income and (to a lesser extent) the structure of hospital expenditures mainly in the nineteenth and twentieth century. Both studies are social histories that strive to explain the emergence of welfare states and that deal with numerous questions about how social and institutional change influenced hospital finance. Those question include, for example: the rise of voluntary, charitable hospitals in Britain in the early eighteenth century (Croxson, see below Berry), the development and problems of their funding system, and that system's influence on hospital care during the nineteenth and twentieth century; the growing influence of state and local authorities, for instance due to the New Poor Law; the creation of national health insurance in Germany (1883)²⁵ and Britain (1911) as well as earlier or similar forms of funding, such as friendly societies and their payment schemes; and finally the establishment and development of the NHS (1948) and its influence on British health care.²⁶ Furthermore, there are specific studies on hospital contributory schemes in Britain, the importance of philanthropy in British health care, and patients’ payments in interwar Britain.²⁷ There are also some publications about the use of Henry Burdett's Uniform System of Accounts in hospitals and other health institutions and its influence on the structure and administration of hospital finances.²⁸ But as Florian Gebreiter and William J. Jackson have noted, these studies have been almost exclusively ‘UK-centric’²⁹, whereas American,³⁰ French,³¹ or German³² contributions are few and far between.

Furthermore, several studies are situated at the interface between economic history, the history of accounting, and cultural history, and have been published in journals like Accounting, Business & Financial History,³³ Accounting, Organisations and Society,³⁴ Accounting, Auditing & Accountability Journal,³⁵ or Accounting History.³⁶ They deal with various aspects of hospital accounting and appear to comprise a subfield of accounting history. Amanda Berry, for instance, investigates the financial management and funding of voluntary hospitals in Bristol, Northampton, Devon, and Exeter in the second half of the eighteenth and the early nineteenth centuries. In these hospitals, which were funded by donations, accounting was intended not just to administer and manage financial resources. In a competitive marketplace of charities, accounting as manifested in public ‘accounts’ and reports was also needed to prove and justify financial transactions and to demonstrate that donations were being properly and efficiently used for the common good. Furthermore, in order to elicit donations from potential benefactors and to exert pressure on members of ‘polite society’ who had not yet contributed, donors were acknowledged by publishing their names in the accounts. Berry's study shows that even mid-sized hospitals employed sophisticated accounting practices in the mid-eighteenth century. Moreover, Berry's work illustrates how accounting went beyond the mere managing of finances and could also serve to set exemplary standards within a gift economy,³⁷ as a social and cultural function designed to solicit further donations.³⁸ Andy Holden et al. analyse the moral economies of hospital accounting in the context of welfare and poor relief, using the example of the Newcastle infirmary in the second half of the nineteenth century.³⁹ The many aims of hospital accounting have also been emphasised by Paolo Quattrone, who has studied the accounting system of the Jesuits in the sixteenth and seventeenth centuries, and Enrico Bracci et al., who investigate the accounting system of Saint Anna Hospital in Ferrara at the end of the sixteenth century.⁴⁰ Again, accounting was more than simply the administration of financial transactions or of the hospital's (or the religious order's) economy; it also attested to and manifested institutional charity. Bookkeeping and accounting were involved in and part of a divine economy (göttliche Ökonomie).⁴¹ Keeping accounts made the bookkeeper accountable both to himself and to God. James Aho argues that in the late medieval and early modern eras, when official Church dogma regarded profit-making as morally suspect, bookkeeping allowed people to justify their actions vis-à-vis the state (or the investor), the community, and God, and to certify ‘that for everything […] earned something of equal value had been returned, and that for everything meted out something else was deserved’.⁴² Further studies on hospital accounting in early modern Bologna, Verona, and Düsseldorf also refer to the multi-dimensional aspects of bookkeeping and its ‘calculating with eternity’ [Rechnen mit der Ewigkeit], as the title of Brigitte Pohl-Resl's book on a medieval Viennese hospital implies.⁴³ Yet these studies also demonstrate just how sophisticated accounting had already become by the sixteenth century, both generally⁴⁴ and in hospitals.

The studies on hospital accounting deal with hospital finances in all their different and multi-dimensional functions, at the interface between charity, philanthropy, medical profession, local government, welfare, and national health. But these multi-disciplinary perspectives are often disconnected, leaving an important gap at the interface between different fields of research: specifically, they fail to explore the reciprocal relationship and mutual interactions between accounting and its calculative practices and administrative techniques on the one hand, and medicine and medical knowledge on the other.

Methodological approach

This volume aims to combine these different perspectives. Spanning a period of nearly five centuries (1500–2000), the contributions address questions of how calculative practices changed over time and for what reasons, and what effects these changes have had on medicine and medical knowledge. More precisely, we are asking: who is doing the accounting in hospitals and other health institutions? What logic are they following? Why and for whom are health institutions engaged in accounting? And what are the effects of accounting on medicine, health, and medical knowledge? These questions can be summed up as follows: what roles have accounting and similar economic practices played in everyday medical modes of knowing? How do such practices generate information about medical costs, and in what ways are such data transformed into economic knowledge? Under what conditions have these relationships and processes become visible and contested or consciously shaped by actors toward specific ends? What changes can be observed over time, and what differences exist between countries or political and economic systems?

The chapters examine the different meanings of accounting with the aim of answering the key question of how accounting and calculative practices affected medical knowledge and practice, i.e. how they affected diagnosis and disease classification, the conceptual and economic organisation of medical research, the nature of prognosis and treatment, patients’ self-observation and self-medication, and not least the power of hospital or national health budgets to shape everyday medical issues.

The link between accounting and medicine, between calculative practices and the generation of medical knowledge, will be discussed from a praxeological perspective that focuses on practices and processes. Hitherto unconnected research strands will thereby be brought together, including both general historical and social science studies on health economics, health markets, and their regulation, as well as more specific explorations in the history of hospital accounting. The methodological conceptualisation of this volume combines four approaches:

(1) Since accounting is examined as a calculative practice, praxeological considerations have to be taken on board. In the sense of ‘looking at paperwork’,⁴⁵ calculative practices as well as the practice of bookkeeping and the associated paper technologies between the sixteenth and the end of the twentieth century will be examined in detail. In recent years, numerous publications from different disciplines like the history of science or cultural and media studies have appeared on the epistemic effects of paperwork or paper technologies on writing practices and their materiality in science and medicine.⁴⁶ In his article ‘Paperwork: the state of the discipline’, Ben Kafka argues that mostly Anglo-American historiography in the 1960s and 1970s produced a series of important and interesting studies. ‘By looking through paperwork’, these social-scientific studies succeeded in reconstructing the lives of ordinary men and women. But at the same time, the studies were not ‘looking at paperwork’, i.e. at the conditions of production and reproduction of the sources. In addition to processes and practices, we turn our attention to the production of numbers and to the very objects and materiality of accounting systems, focusing not so much on numbers themselves as the mere result or output of accounting practices, but rather on how the numbers, the balance sheets, the tables, and statistics emerge, for what reasons the counting is done, and what effects writing, reckoning, and calculating practices produce?

But our perspective is not limited to the purpose and function of accounting: we are also interested in the context of the individual figures, tables, lists, etc. in which they were actually created. As the example of the poor box shows, the question of how and why something has been collected cannot be separated from subsequent administrative processes. If we want to understand these processes, including all of their financial, moral, and epistemological implications, it is also necessary to ask how and why certain objects were collected and counted. In this sense, the contributions to this volume engage questions of how and for what purpose money, goods, and data were gathered, how these objects were subsequently processed and used, and what implicit and explicit effects they had. And so we intend to illustrate the importance of accounting in the making of (medical) knowledge and to decouple it from merely economic and monetary issues, without, however, neglecting its significance for those issues.

(2) As noted, accounting commonly is about figures that compare and analyse